On & off field sports evaluation

ON & OFF FIELD SPORTS
INJURY EVALUATION
K.Soundararajan
11/14/2019 K. Soundararajan, MPT, SRIHER 1

INTRODUCTION
• Sport injuries are diverse in terms of the
mechanism of injury, how they present in
individuals, and how the injury should be
managed.
• Defining exactly what a sports injury is can be
problematic and definitions are not
consistent.
Verhagen et al (2010)

Sports injury may be defined as "damage
to the tissues of the body that occurs as a
result of sport or exercise"
Engebretsen et al (2012)

• The International Classification of Functioning,
Disability and Health (ICF) is one of the most
well know mechanisms and considered the
gold standard for classification of medical
conditions
• But is currently rarely used in the field of
sports medicine.

• For researchers in sport defining simple,
pragmatic, consistent, operational criteria
which describe an injury that can be applied
across a range of sports is vital, particularly
when developing injury surveillance systems.
• Many comprehensive systems have been
developed to classify injury in order to assist
with development of injury surveillance which
can be used across sports

• There are many ways to classify sports injuries
based
on time taken for tissues to become injured,
tissue type affected,
severity of the injury,
which injury the individual presents with.

ACUTE
• Injury occurs suddenly to previously normal
tissue.
• Acute injuries occur due to sudden trauma to the
tissue, with the symptoms of acute injuries
presenting themselves almost immediately.
• The principle in this instance is that the force
exerted at the time of injury on the tissue (i.e.
muscle, tendon, ligament, and bone) exceeds the
strength of that tissue.
• Forces commonly involved in acute injury are
either a direct or indirect.

Direct / Contact Injury
A direct injury is caused by an external blow or
force.
• A collision with another person e.g.during a
tackle in rugby or football
• Being struck with an object e.g. a basketball or
hockey stick

Indirect / Non-Contact Injury
• An indirect injury can occur in two ways:
• The actual injury can occur some distance from
the impact site e.g. falling on an outstretched
hand can result in a dislocated shoulder
• The injury does not result from physical contact
with an object or person, but from internal forces
built up by the actions of the performer, such as
may be caused by over-stretching, poor
technique, fatigue and lack of fitness.

Common Acute Injuries include
• Ankle Sprain
• Quadriceps Strain
• Clavicular Fracture
• Shoulder Dislocation

Key principles of sports injury
assessment
• Injury evaluation is the first stage of treating
the injury.
• As a sports therapist make sure that you know
what you are working with before you attempt
to advise, treat or rehabilitate your client.
• When assessing clients you will go through
two processes: subjective assessment and
objective assessment.

Subjective assessment
• Subjective assessment of your client is the
‘history taking’ stage of the assessment where
the client describes their injury.
• It is always the first stage of any client
evaluation and precedes any objective testing

• However, you must try to get your client to be
as clear as possible with the information that
they give.
• This is called the subjective stage because the
client is offering you information about the
injury – such as how the injury has progressed
or regressed
• since it first occurred or how much pain they
have been in – you cannot be certain of the
accuracy of this information as people might
over-exaggerate or play down the significance
of an injury.

Ask your client to elaborate on any points raised
through the subjective assessment that you consider to
be important for the treatment and management of
the injury.
Below are some suggestions for questions to ask when
conducting a subjective assessment of your client,
although the questions will be determined by your
client’s activities.
• How and when did the injury happen?
• Onset of injury. Was it sudden? Trauma?
• What were the surface/ground conditions like?
• Current signs and symptoms?

• What problems does the injury currently cause you?
Are they performance related? Do they affect everyday
life?
• Does anything make the symptoms better/ worse?
• Do you have any pain/discomfort?
If yes, locality? Type of pain? Local/referred?
Constant/ intermittent?
What has happened with pain over last 24 hours?
• Are you taking any medication?
• General health? Recent weight loss/gains and
reasons? Previous conditions? Previous injury?
• Red, yellow, blue, black, orange flags/ precautions.

Objective assessment
• Information about the injury by looking at the
injury site, palpation, observing specific
functional movements and completing any
specific tests.
• Your aim during this stage of assessment is to
determine the degree of functional losses and
gains during the injury period.

Observation
You will gain a better picture of the injury status if
you can observe the client (and particularly the
affected part) performing different types of
movements. This allows you to assess
progression/ regression in the injury.
Consider the following aspects where possible
and appropriate:
• watch the player walk into your clinic or off the
field – is there a limp?
• functional ability sitting/standing
• undressing/redressing items of clothing specific to
the injury site.

Whether your client is standing, seated or lying,
always look for and assess:
• muscle wastage
• swelling and the degree of swelling
• any previous scars
• any general lumps, cysts, bursae
• discoloration
• postural considerations
• position of the patella
• foot position (flat, pronated, supinated?).

Palpation
Palpation is a key part of the objective assessment.
When you examine your client using palpation they could be standing,
sitting or lying (prone and supine).
This part of the consultation has two parts:
1) General assessment of the tissues within the area
2) precise palpation to try to find areas of tension, sensitivity or any
trigger points.
When palpating your client you should include the following.
• Feel for heat using the back of your hand.
• Any swelling? Is it soft/hard?
• Pain? Degree of pain using pain scale (1–10). Area of pain? Type of pain?
• Palpate all bony points, ligaments, tendons, muscles, along joint lines.

Movements
The final important part of your objective
assessment is the movements that your client can
perform. Three types of movement are used to
assess the injury status: active, passive and
resisted.
• Active movements are movements performed by
the client.
• Passive movements are movements performed by
the sports therapist (e.g. manually flexing the leg
of the client at the knee).
• Resisted movements are movements performed
by the client and resisted by the sports therapist

When using these different types of movement
with your client, your client should be tested
through a ‘pain free’ movement. Consider some
of these questions when working with your
client:
• What range of movement is achieved pain free?
• What is the limiting factor in preventing
movement?
• How does the movement gained compare to the
uninjured side?

Specific testing
• As part of your injury evaluation, you will need
to conduct different tests to give you a better
idea of the progression or regression of the
injury.
• The tests used by sports therapists to assess
injury status include range of movement
testing, gait analysis, manual muscle tests and
ligament stress tests.

Management on the Field

Management of the athlete who has collapsed
begins before the injury occurs with proper
preparation.
Depending on the location and level of the event,
resources may be limited.
At the very least, it is imperative that physician
has quick access to a phone& medical kit or
supplies and most importantly, ability to
transport the patient to a medical facility.

• When an athlete collapses, it is important to
consider both medical and surgical problems.
• The list of potential problems is long, ranging
from an asthma attack or cardiovascular event
to a severe head injury or musculoskeletal
trauma.

The initial assessment always should begin
with a primary survey, which is performed
on the field before moving the patient.
It is helpful to adopt an ABCDE approach:

• The purpose of the survey is to identify
promptly life-, limb-, or organ-threatening
injuries that need immediate attention.
• It is important to “clear” each step before
moving the player off the field.

• A secondary survey is performed on the
sidelines to identify any further significant
limb or organ injuries.
• A careful head-to-toe examination includes
detailed examination of any system or joint of
specific concern.

• By using the ABCDE approach, hemodynamic
instability from anoccult fracture should be
identified readily.
• In the acute setting, most musculoskeletal
trauma may be treated temporarily with modified
activity or rest, ice for the first 72 hours (not
heat), compression,and elevation (RICE).
• The injured area may require splinting, depending
on the severity and type of injury.
• Any major injury with possible fracture or
ligamentous disruption should be referred to the
hospital for assessment

• Suspected neurovascular injury or compartment
syndrome requires immediate referral for assessment.
• If a joint is dislocated and there is neurovascular
compromise, the clinician who is trained in reduction
technique may attempt a reduction of the joint on the
field.
• In the acute setting, sedation may not be required.
• An unsuccessful first reduction attempt may suggest
that soft tissue is interposed in the joint or that there is
an associated unstable fracture.
• In any case, immediate referral for assessment and
treatment is appropriate.

• It is the responsibility of the sports medicine physician
to determine further management for the fallen
athlete. Options include:
1) sending the patient to the hospital for treatment or
further investigation,
2) taking the player out of play and arranging follow-up,
3) Observing player on sidelines for potential return to
play,
4) returning the athlete to play.
Clearing a player for return to play involves
determining whether the athlete can participate in the
sport safely, can play effectively, and canperform pain-
free.

• If safety is a concern, play is not allowed, but if
the athlete can play safely, albeit with pain,
the contraindications for return to play are
relative.
• In such cases the effectiveness of play, often in
consultation with the coach, may determine
eligibility to return

Musculoskeletal Trauma
• Musculoskeletal trauma is the most common
type of injury that the sports physician will
encounter.
• During the primary survey, it is important to
identify musculoskeletal trauma with potential
hemodynamic complications or associated
neurovascular injury.

• For example, large volumes of blood may be
lost into third spaces in the body following
pelvic or femur fractures.
• Up to 1,000 mL of blood may be lost into the
muscle of the thigh, resulting in hemodynamic
instability after a femur fracture.

• Neurovascular injuries may occur following
dislocation, fracture, or subsequent
compartment syndrome.
• Joint dislocations occur most commonly at the
shoulders, elbows, and knees.
• Because a dislocated joint may reduce
spontaneously, such a dislocation should be
suspected when a joint is unstable and more
than one ligament is injured.
• Nerves, arteries, and veins around such joints
may be injured at the time of dislocation

• Studies of knee dislocations note a 29% to 40%
incidence of associated arterial injury and a 9% to
49% incidence of nerve injury.
• A limb with arterial compromise has a window of
6 hours from injury before irreversible tissue
damage occurs.
• A compartment syndrome in the forearm or
lower extremities may occur from bleeding and
ischemia distal to the dislocation despite palpable
pulses.
• For these reasons, a careful neurovascular
examination must be performed.

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